CDC Recommendations for a Community Plan for
the Prevention and Containment of Suicide Clusters

OUTLINE

A community should review these recommendations and develop
its own response before the onset of a suicide cluster.

The response to the crisis should involve all concerned
sectors of the community and should be coordinated by:

Coordinating Committee, which manages the day-to-day
response to the crisis, and

Host Agency, whose responsibilities would include "housing"
the plan, monitoring the incidence of suicide, and calling
meetings of the Coordinating Committee when necessary.

The relevant community resources should be identified.

The response plan should be implemented under either of the
following two conditions:

When a suicide cluster occurs in the community, or

When one or more deaths from trauma occur in the community,
especially among adolescents or young adults, which may
potentially influence others to attempt or complete
suicide.

If the response plan is to be implemented, the first step
should be to contact and prepare those groups who will play
key roles in the first days of the response.

The response should be conducted in a manner that avoids
glorification of the suicide victims and minimizes
sensationalism.

Persons who may be at high risk of suicide should be
identified and have at least one screening interview with a
trained counselor; these persons should be referred for
further counseling or other services as needed.
VIII. A timely flow of accurate, appropriate information should

be provided to the media.
IX. Elements in the environment that might increase the

likelihood of further suicides or suicide attempts should
be identified and changed.
X. Long-term issues suggested by the nature of the suicide

cluster should be addressed.
INTRODUCTION

Recent suicide clusters among teenagers and young adults have
received national attention, and public concern about this issue
is growing. Unfortunately, our understanding of the causes and
means of preventing suicide clusters is far from complete. A
suicide cluster may be defined as a group of suicides or suicide
attempts, or both, that occur closer together in time and space
than would normally be expected in a given community. A
statistical analysis of national mortality data indicates that
clusters of completed suicide occur predominantly among
adolescents and young adults, and that such clusters account for
approximately 1%-5% of all suicides in this age group (1).
Suicide clusters are thought by many to occur through a process
of "contagion," but this hypothesis has not yet been formally
tested (2,3). Nevertheless, a great deal of anecdotal evidence
suggests that, in any given suicide cluster, suicides occurring
later in the cluster often appear to have been influenced by
suicides occurring earlier in the cluster. Ecologic evidence also
suggests that exposure of the general population to suicide
through television may increase the risk of suicide for certain
susceptible individuals (4,5), although this effect has not been
found in all studies (6,7).

The Centers for Disease Control (CDC) has assisted several
state and local health departments in investigating and
responding to apparent clusters of suicide and suicide attempts.
These clusters created a crisis atmosphere in the communities in
which they occurred and engendered intense concern on the part of
parents, students, school officials, and others. In the midst of
these clusters of suicides or suicide attempts, community leaders
were faced with the simultaneous tasks of trying to prevent the
cluster from expanding and trying to manage the crisis that
already existed. Potential opportunities for prevention were
often missed during the early stages of response as community
leaders searched for information on how best to respond to
suicide clusters.

The recommendations contained in this report were developed to
assist community leaders in public health, mental health,
education, and other fields to develop a community response plan
for suicide clusters or for situations that might develop into
suicide clusters. A workshop for developing these recommendations
was jointly sponsored by the New Jersey State Department of
Health and CDC on November 16-17, 1987, in Newark, New Jersey.*
Participants in that workshop included persons who had played key
roles in community responses to nine different suicide clusters.
They were from a variety of different sectors including
education, medicine, local government, community mental health,
local crisis centers, and state public health and mental health.
Also participating in this workshop were representatives from the
National Institute of Mental Health (NIMH), the Indian Health
Service (IHS), the American Association of Suicidology (AAS), and
the Association of State and Territorial Health Officials
(ASTHO).

These recommendations should not be considered explicit
instructions to be followed by every community in the event of a
suicide cluster. Rather, they are meant to provide community
leaders with a conceptual framework for developing their own
suicide-cluster-response plans, adapted to the particular needs,
resources, and cultural characteristics of their communities.
These recommendations will be revised periodically to reflect new
knowledge in the field of suicide prevention and experience
acquired in using this plan.

Certain elements of the proposed plan for the prevention and
containment of suicide clusters are quite different from those of
crisis-response plans for other community emergencies. These
differences are primarily attributable to the potentially
contagious nature of suicidal behavior and to the stigma and
guilt often associated with suicide. Other elements of the
proposed plan, however, are germane to crisis-response plans in
general. Therefore, state and local health planners might
consider whether the plan they develop from these recommendations
should be integrated into existing guidelines for managing other
emergencies or mental health crises.

A community should review these recommendations and develop
its own response plan before the onset of a suicide
cluster.
Comment. When a suicide cluster is occurring in a community--or
when such a cluster seems about to occur--several steps in our
recommended response plan should be taken right away. If such a
timely reaction is to be possible, the response plan must
necessarily already be developed, agreed upon, and understood by
all the participants at the onset of the crisis. The recommended
response requires a great deal of coordination among various
sectors of the community. Such coordination is sometimes
difficult to establish at the best of times and may be even more
difficult to establish in the face of a crisis.

In the early days of an evolving suicide cluster there has
typically been a great deal of confusion. There is often a sense
of urgency in the community that something needs to be done to
prevent additional suicides, but there has usually been little
initial coordination of effort in this regard. Moreover,
community members often disagree about precisely what should be
done to prevent a cluster from expanding. In almost every case,
communities ultimately develop some sort of plan for responding
to the crisis in a coordinated manner, but opportunities for
prevention are often missed in the crucial first hours of the
response.
II. The response to the crisis should involve all concerned

sectors of the community and should be coordinated as
follows:

Individuals from concerned agencies--education, public
health, mental health, local government, suicide crisis
centers, and other appropriate agencies-- should be
designated to serve on a coordinating committee, which
would be responsible for deciding when the response plan
should be implemented and coordinating its implementation.

One agency should be designated as the "host" agency for
the plan. The individual representing that agency would
have the following responsibilities:

Call the initial meeting of the coordinating committee
before any crisis occurs so that these recommendations
can be incorporated into a plan that reflects the
particular resources and needs of the community (see
Section III, below).

Establish a notification mechanism by which the agency
would be made aware of a potentially evolving suicide
cluster (see Comment, below).

Convene the coordinating committee when it appears that
a suicide cluster is occurring, or when it is suspected
that a cluster may occur due to the influence of one or
more recent suicides or other traumatic deaths (see
Section IV, below). At this initial meeting, the
members of the coordinating committee could decide
whether to implement the community response plan and
how extensive the response needs to be.

Maintain the suicide-cluster-response plan. The
coordinating committee should meet periodically to
assure that the plan remains operational.

Revise the community plan periodically to reflect new
knowledge in the field of suicide prevention, the
community's experiences in using the plan, and changes
in the community itself.

Comment. Every effort should be made to promote and implement
the proposed plan as a community endeavor. During past suicide
clusters, a single agency has often found itself "in the hot
seat," that is, as the focal point of demands that something be
done to contain the suicide cluster. No single agency, however,
has the resources or expertise to adequately respond to an
evolving suicide cluster. Moreover, the emergence of one agency
as the sole focus for responding to an apparent suicide cluster
has several unfortunate consequences. The agency and its
representatives run the danger of becoming scapegoats for a
community's fear and anger over the apparent cluster. Such a
focus can potentially blind a community to other valuable
resources for responding to the crisis and to basic community
problems that may have engendered the crisis.

The concept of a "host" agency was developed because--even
though the response will involve a variety of different agencies
and community groups--one person must necessarily take
responsibility for establishing a notification mechanism,
maintaining the response plan, and calling meetings of the
coordinating committee as outlined above. Which agency should
serve as the host agency should be decided by each community. In
past clusters, for example, a school district, a municipal
government, a mental health association, and even a private,
nonprofit mental health center have taken the lead in organizing
their community's response. State or local public health or
mental health agencies might also serve as host agencies for the
plan. The role of host agency might also be rotated among the
various agencies represented on the coordinating committee.

The notification mechanism by which the host agency would be
made aware of a potentially evolving suicide cluster would vary
from community to community. In small communities, one death of a
teenager by suicide might be unusual, and information about the
death would be quickly transmitted to a county-level host agency.
In some large communities, however, there are many suicides each
year among young persons. Clearly, a more formal system would be
needed in such a county to notify the host agency when an unusual
number of suicides had occurred in a particular high school or
municipality.

Determining whether to implement the response plan is not an
all-or-nothing decision. Indeed, an important function of the
coordinating committee is to decide to what extent the plan will
be implemented. In situations in which it is feared that a
cluster of suicides may be about to start, for example, the
implementation of the plan might be quite subtle and limited,
whereas in the event of a full-blown community crisis the
implementation should be more extensive.
III. The relevant community resources should be identified.

In addition to the agencies represented on the coordinating
committee, the community should also seek to identify and enlist
help from other community resources, including (but not limited
to):

and local government, if not already represented on the
coordinating committee

Comment. The roles of each of the above groups should be
defined as clearly as possible in the response plan before any
crisis occurs. These roles should be agreed upon and reviewed by
persons representing those groups. Most of those involved in the
response will already know how to perform their particular
duties. However, appropriate training for the staff of these
groups should be provided as necessary (8). For example, if it is
deemed desirable to conduct surveillance for suicide attempts
through hospital emergency departments, officials at the state or
local public health department might help design the system and
train the emergency department staff. Other potential resources
for training and counseling include state and local mental health
agencies, mental health and other professional associations, and
suicide crisis centers.

It is particularly important that representatives of the local
media be included in developing the plan. In at least one
community faced with a suicide cluster, the media collaborated in
preparing voluntary guidelines for reporting suicide clusters.
Although frequently perceived to be part of the problem, the
media can be part of the solution. If representatives of the
media are included in developing the plan, it is far more likely
that their legitimate need for information can be satisfied
without the sensationalism and confusion that has often been
associated with suicide clusters.

The following example representing a composite of several
actual suicide clusters illustrates the need for inclusion of and
cooperation among many community organizations. Suppose that two
high school students from the same school commit suicide in
separate incidents on a weekend during the regular school year.
The coordinating committee decides that these two deaths may
increase the risk of suicide or attempted suicide among other
students. The responsibilities of some of the relevant community
resources might be as follows: School officials might be
responsible for announcing the deaths to the students in an
appropriate manner (discussed below, Section VI). School
counselors and teachers might assist in identifying any students
whom they think are at high risk; students in the school might
also help in this regard. The local mental health agency might
provide counselors to work with troubled students, as well as
supply training and support for the teachers. Emergency
departments of community hospitals might set up a suicide-attempt
surveillance system that would increase the sensitivity with
which suicide attempters were identified and would ensure proper
referral of the attempters for counseling. Hotlines might help
identify potential suicide attempters, and police might assist in
locating such persons when appropriate. Police may also help by
identifying and maintaining contact with such high-risk persons
as high school dropouts and those with a history of delinquency.
Local government or public health authorities might help
coordinate these various efforts, if so designated by the
coordinating committee.
IV. The response plan should be implemented under either of the

following two conditions:

When a suicide cluster occurs in the community; that is,
when suicides or attempted suicides occur closer together
in space and time than is considered by members of the
coordinating committee to be usual for their community;

OR --

When one or more deaths from trauma occur in the community
(especially among adolescents or young adults) which the
members of the coordinating committee think may potentially
influence others to attempt or complete suicide.

Comment. It is difficult to define a "suicide cluster"
explicitly. Clearly, both the number and the degree of
"closeness" of cases of suicide in time and space that would
constitute a suicide cluster vary depending on the size of the
community and on its background incidence of suicide. But when a
community considers that it is facing a cluster of suicides, it
is essentially irrelevant whether the incident cases of suicide
meet some predefined statistical test of significance. With the
suddenly heightened awareness of and concern about suicide in
such a community, steps should be taken to prevent further
suicides that may be caused in part by the atmosphere, or
"contagion," of the crisis.

In several clusters of suicides or suicide attempts, the crisis
situation was preceded by one or more traumatic
deaths--intentional or unintentional--among the youth of the
community. For example, in the 9 months preceding one cluster of
four suicides and two suicide attempts among persons 15-24 years
of age, there were four traumatic deaths among persons in the
same age group and community--two from unintentional injuries,
one from suicide, and one of undetermined intentionality. One of
the unintentional-injury deaths was caused by a fall from a
cliff. Two of the persons who later committed suicide in the
cluster had been close friends of this fall victim; one of the
two had witnessed the fall.

The hypothesis that a traumatic death can kindle a suicide
cluster regardless of whether it is caused by intentional or
unintentional injuries has not yet been tested. Nevertheless, the
available anecdotal evidence suggests that some degree of
implementation of the response plan be considered when a
potentially influential traumatic death occurs in the
community--especially if the person who dies is an adolescent or
young adult.

We should emphasize that the fear of a contagious effect of
suicide is not the only reason to implement this plan. For
example, suppose that in the wake of some local economic downturn
a community noted an excess of suicide deaths among persons who
had been laid off from work. This would be a suicide cluster, and
it would be entirely appropriate for the coordinating committee
to implement the response plan. It is irrelevant that the
suicides are not apparently related to contagion from previous
suicides but to a "common-source" problem, since there is an
identified population (laid-off workers) potentially at a
suddenly increased risk of suicide.

Whether and when to implement the response plan should be
determined by the coordinating committee. At this stage of our
understanding of suicide clusters, we cannot specify that the
response plan should be implemented only under a particular list
of circumstances. Until further scientific investigation and
experience with suicide clusters provides us with a more
empirical basis for deciding when to implement the response plan,
we must rely on prudent judgments by community leaders regarding
the potential for further suicides in their communities.
V. If the response plan is to be implemented, the first step

should be to contact and prepare the various groups
identified above.

Immediately notify those who will play key roles in the
crisis response of the deaths that prompted the
implementation of the response plan (if they are not
already aware of them).

Review the respective responsibilities and tasks with each
of these key players.

Consider and prepare for the problems and stresses that
these persons may encounter--burnout, feelings of guilt if
new suicides occur, and the like--as they carry out their
assigned tasks.

Comment. Timely preparation of the groups involved is critical.
In a past cluster that began with a scenario similar to that
described in Section III above, the teachers and the students
both heard about the suicide deaths at the same time over the
school loudspeaker. The teachers were entirely unprepared to deal
with the emotional response of the students and did not know what
to say to them or where to refer those who were most upset. It
would have been far preferable to have called a pre-school
meeting with the teachers to outline the problem, discuss the
appropriate roles of the teachers, and announce the various
resources that were available (9). Support staff at the
school--secretaries, bus drivers, janitors, nurses, and
others--might also have been included at the meeting. Such
preparation could have been of enormous help in several past
suicide clusters.
VI. The crisis response should be conducted in a manner that

avoids glorifying the suicide victims and minimizes
sensationalism.

Community spokespersons should present as accurate a
picture as possible of the decedent(s) to students,
parents, family, media, and others (see Section VIII,
below).

If there are suicides among persons of school age, the
deaths should be announced (if necessary) in a manner that
will provide maximal support for the students while
minimizing the likelihood of hysteria.

Comment. Community spokespersons should avoid glorifying
decedents or sensationalizing their deaths in any way (9). To do
so might increase the likelihood that someone who identifies with
the decedents or who is having suicidal thoughts will also
attempt suicide, so as to be similarly glorified or to receive
similar positive attention. One community that had had several
suicides among high school students installed a "memorial bench"
on the school grounds, with the names of the suicide victims
engraved on the bench. Although this gesture was undoubtedly
intended to demonstrate sincere compassion, such a practice is
potentially very dangerous.

Spokespersons should also avoid vilifying the decedents in an
effort to decrease the degree to which others might identify with
them. In addition to being needlessly cruel to the families of
the decedents, such an approach may only serve to make those who
do identify with the decedents feel isolated and friendless.

If the suicide victims are of school age, the deaths should be
announced privately to those students who are most likely to be
deeply affected by the tragedy--close friends, girl friends, boy
friends, and the like. After the teachers are briefed (see
Section V), the suicide deaths might be announced to the rest of
the students either by individual teachers or over the school
loudspeaker when all the students are in homeroom or some other
similarly small, supervised groups. Funeral services should not
be allowed to unnecessarily disrupt the regular school schedule.
VII. Persons who may be at high risk should be identified and

have at least one screening interview with a trained
counselor; these persons should be referred for further
counseling or other services as needed.

Active measures:

Identify relatives (siblings, parents, children) of the
decedents and provide an opportunity for them to
express their feelings and to discuss their own
thoughts about suicide with a trained counselor.

Similarly, identify and provide counseling for boy
friends/girl friends, close friends, and fellow
employees who may be particularly affected by the
deaths.

Strategies to identify associates of the decedents or
others who may be at increased risk of suicide might
include: identifying the pall bearers at the funeral
services of the decedent(s); checking with the funeral
director regarding visitors who seemed particularly
troubled at the services; keeping a list of hospital
visitors of suicide attempters; and verifying the status of
school absentees in the days following the suicide of a
student.
3. In the case of suicides among school-age persons,

enlist the aid of teachers and students in identifying
any students whom they think may be at increased risk
of suicide.
4. Identify and refer past and present suicide attempters

for counseling if these persons were substantially
exposed to suicide (see below), regardless of whether
they were close friends of the decedents.

"Substantially exposed" persons would include, for
example, students in the same high school or
workers at the same job location as the suicide
victims. In past suicide clusters, such persons
have committed or attempted suicide even though
they did not personally know the victims who had
committed suicide earlier in the cluster.

Identify and refer persons with a history of depression
or other mental illness or with concurrent mental
illness who were substantially exposed to suicide (see
Section VII.A.4.a, above).
6. Identify and refer persons whose social support may be

weakest and who have been substantially exposed to
suicide. Examples of such persons include:

students who have recently moved into the school
district

students who come from a troubled family

persons who have been recently widowed or divorced,
or who have recently lost their jobs.

Passive measures:

Consider establishing hotlines or walk-in suicide
crisis centers--even temporarily--if they do not
already exist in the community; announce the
availability of such hotlines/centers.

Provide counselors at a particular site (such as
school, church, community center) and announce their
availability for anyone troubled by the recent deaths.

If suicides have occurred among school-age persons,
provide counselors in the schools if possible;
announce their availability to the students.

Enlist the local media to publish sources of
help--hotlines, walk-in centers, community meetings,
and other similar sources.

Make counseling services available to persons involved
in responding to the crisis as well.

Comment. The recommendations for active measures to identify

persons at high risk of suicide are based largely on scientific
evidence that certain factors increase the risk of suicide. For
example, mental illness (especially depressive illness) (10) and
a history of past suicide attempts (11) are both strong risk
factors for suicide. Certain sociologic factors such as
unemployment (12), being widowed or divorced (13,14), other
bereavement (15,16), and mobility (17), also appear to be
important risk factors for suicide.

The role of imitation or "contagion" is, as we noted above,
less well-established than the risk factors listed above.
Nevertheless, the anecdotal evidence from suicide clusters is
quite compelling, and several of the specific suggestions made
above regarding who should be considered for screening are based
on such evidence. For example, in one high school-based cluster,
two persons who committed suicide late in the cluster had been
pall bearers at the funerals of suicide victims who had died
earlier in the cluster. It is likely that persons who are exposed
to one or more of the aforementioned risk factors--depression or
recent loss, for example--may be more susceptible to a contagious
effect of suicide.
VIII. A timely flow of accurate, appropriate information should
be provided to the media.

Make certain that a single account of the situation is
presented by appointing one person as information
coordinator. This person's duties would include:

meeting frequently with designated media spokespersons
(see Section VIII-B, below) to share news and
information, and to make certain that the spokespersons
share a common understanding of the current situation

maintaining a list of local and national resources for
appropriate referral of media inquiries

scheduling and holding press conferences.

Appoint a single media spokesperson from each of the
relevant community sectors--public health, education,
mental health, local government, and the like.

Each sector represented on the coordinating committee
should have a spokesperson. This person is not
necessarily the same representative who serves on the
coordinating committee.

Spokespersons from additional agencies or public groups
may be designated as appropriate.

These spokespersons should provide frequent, timely access
to the media and present a complete and honest picture of
the pertinent events. When appropriate, regularly scheduled
press conferences should be held.

Avoid "whitewashing"--that is, saying that everything
is under control or giving other assurances that may
later prove unwarranted. This practice would undermine
the credibility of the community spokespersons.

Discuss the positive steps being taken, and try to get
the media to help in the response by reporting where
troubled persons can go for help.

The precise nature of the methods used by decedent(s) in
committing suicide should not be disclosed. For example, it
is accurate to state that an individual committed suicide
by carbon monoxide poisoning. But it is not necessary--and
is potentially very dangerous--to explain that the decedent
acquired a hose from a hardware store, that s/he hooked it
up to the tail pipe of a car, and then sat in a car with
its engine running in a closed garage at a particular
address. Such revelations can only make imitative suicides
more likely and are unnecessary to a presentation of the
manner of death.

Enlist the support of the community in referring all
requests for information to these spokespersons.
Comment. If some suicide clusters spread through

"contagion," the vehicle for such contagion is information,
perhaps sensationalized information, about the suicides that have
occurred. The role of the media in causing or exacerbating a
suicide cluster is controversial, but some investigators will no
longer even discuss an evolving suicide cluster with media
representatives for fear that newspaper or television accounts
will lead to further suicides. Although a definitive
understanding of this issue must be left to future research, it
is prudent in the meantime to try to prevent needlessly
sensationalized or distorted accounts of evolving suicide
clusters.

The media spokespersons should meet as a group and with the
information coordinator regularly; under certain circumstances,
they may need to check with each other several times a day.
Gaining the cooperation of the community in referring requests to
these spokespersons is a formidable task and will require early
and ongoing efforts if it is to be accomplished. It may be
helpful to assure community members that it is all right to say
PnoP' to media phone calls or requests for interviews.

The cooperation of parents is especially essential in the
context of a school-based suicide cluster. Interviews with
students about the suicide of one or more of their peers can be
very stressful. Parents who do not wish to have their children
interviewed may be able to prevent such interviews by refusing to
sign a release statement. A handout addressing how media requests
should be handled might be prepared and distributed to parents,
students, and other appropriate persons.

Gaining the cooperation of media representatives in this regard
is also a formidable task. In the midst of a crisis, the frequent
presentation of accurate and credible information is the best
means of establishing such cooperation. It is preferable,
however, to develop a working relationship with local media
representatives before a crisis occurs.
IX. Elements in the environment that might increase the

likelihood of further suicides or suicide attempts should
be identified and changed.
Comment. If a particular method or site was used in previous
suicides or suicide attempts, modification efforts should be
addressed to these methods or sites first. For example, if the
decedent(s) jumped off a particular building, bridge, or cliff,
barriers might be erected to prevent other such attempts. If the
decedent(s) committed suicide by carbon monoxide poisoning in a
particular garage, access to that garage should be limited or
monitored or both. If the decedent(s) committed suicide with a
firearm or by taking an overdose of drugs, then restricting
immediate access to firearms or to potentially lethal quantities
of prescription drugs should be considered. In the case of
suicides committed in jail, belts and other articles that may be
used to commit suicide by hanging should be removed, and
vigilance over the jail cells should be increased. Some of these
modifications can be accomplished directly through the efforts of
the coordinating committee, while others (limiting access to
drugs or firearms) can only be suggested by the committee for
others to consider.

Although immediate environmental modifications may be suggested
by methods used in previous suicides, the modifications need not
be limited only to those methods. If there is concern, for
example, that the risk of suicide for particular adolescents may
have been increased because of the influence of previous
traumatic deaths, then common methods of suicide--firearm injury,
carbon monoxide poisoning,overdose--should be made temporarily
unavailable if possible. The coordinating committee should
consider a variety of potentially relevant environmental factors
in developing this element of the response strategy.
X. Long-term issues suggested by the nature of the suicide

cluster should be addressed.
Comment. Common characteristics among the victims in a given
suicide cluster may suggest that certain issues need to be
addressed by the community. For example, if the decedent(s) in a
particular suicide cluster tended to be adolescents or young
adults who were outside the main stream of community life,
efforts might be made to bring such persons back into the
community. Or, if a large proportion of the suicide attempters or
completers had not been suspected of having any problems, then a
system should be developed (or the present system altered) so
that troubled persons could receive help before they reached the
stage of overt suicidal behavior.

Communities should consider establishing a surveillance system
for suicide attempts as well as completed suicides.
Suicide-attempt surveillance systems are almost nonexistent; yet
the benefits of such systems are potentially great. In the
context of a suicide cluster, such a system would allow persons
who have attempted suicide in the past to be identified. Such
persons are known to be at high risk of further suicide attempts.
It would also allow for ongoing identification of high-risk
persons during and after the current crisis. Communities should
consider establishing suicide-attempt surveillance systems in
their local emergency departments or wherever appropriate.

This plan should be modified according to the community's
experience with its operation. Parts of the plan that have worked
well in a given setting should be stressed in the updated plan,
and parts that were inapplicable or that did not work should be
excluded. Finally, the Centers for Disease Control requests that
communities that use the plan notify us of their experiences with
the plan to allow appropriate updating of this document. Please
write to:

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